Healthcare Provider Details

I. General information

NPI: 1053918524
Provider Name (Legal Business Name): NICOLE ANNE VANNOIE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. NICOLE ANNE REYNOLDS

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

IV. Provider business mailing address

1277 WRIGHTSTOWN RD
DE PERE WI
54115-9689
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-4600
  • Fax:
Mailing address:
  • Phone: 920-366-5201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10423-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: